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Mother and Family’s View on Exclusive Breastfeeding in Developing Country

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 Mother and Family’s View on Exclusive Breastfeeding in Developing
Country

Iqbal Pramukti1, Michael Hill2, Norehan Binti Mohammad Isa3

1
Fakultas Keperawatan Universitas Padjadjaran, 2Northumbria University, UK, 3Mahsa University,
Malaysia
E-mail: iqbalrevi@gmail.com

Abstract

Exclusive breastfeeding is something which has a lot of benefit both for mother and baby. It is recommended by
WHO at let for the first six months. Then it also recommended until two years and beyond. In fact, mostly mother
only gave their breastmilk to their babies until two months. The method of this study using systematic review-
metasynthesize which an extensive of the literature was undertaken. Database searched were: MEDLINE, CINAHL,
BioMed Central, Wiley, and EMBASE. Result shown that mother’s view on exclusive breast is an important part in
an attempt to promote breastfeeding desire. Even though their view is influenced by her family and surroundings,
but finally the decision is on her. This concurs with finding of some researcher who found women who have
the experience of breastfeeding, especially within the family, are more likely to choose to breastfeed heir child.

Key words: Exclusive breastfeeding, family, mother

Pandangan Ibu dan Keluarga tentang Asi Eksklusif di Negara Berkembang

Abstrak

Pemberian ASI eksklusif adalah sesuatu yang memiliki manfaat sangat besar baik bagi ihu maupun bayi. Hal ini sangat
direkomendasikan oleh WHO minimal sampai enam bulan pertama kelahiran bayi. Kemudian dapat dilanjutkan
sampai usia dua tahun. Pada kenyataannya, kebanyakan ibu memberikan ASI mereka kepada bayinya hanya sampai
usia bayi dua bulan. Metode yang digunakan adalah systematic review- metasintesis yang mana menggunakan
pencarian literatur secara luas. Database yang dipilih adalah: MEDLINE, CINAHL, BioMed Central, Wiley, dan
EMBASE. Hasil penelitian menunjukkan bahwa pandangan ibu mengenai pemberian ASI eksklusif memiliki peranan
yang penting dalam usaha meningkatkan keinginan untuk menyusui. Walaupun pandangan mereka dipengaruhi oleh
keluarga dan sekitarnya, namun keputusan akhir tetap berada di tangan mereka. Hal ini sejalan dengan beberapa
penelitian yang sudah dilakukan oleh beberapa peneliti sebelumnya yang menyebutkan bahwa wanita yang memiliki
pengalaman dalam menyusui, khususnya di dalam keluarga akan cenderung memutuskan untuk menyusui bayinya.

Kata kunci: ASI eksklusif, keluarga, ibu

Volume 2 Nomor 3 Desember 2014 179

Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
Background
Breastfeeding has a lot of benefits for both
mother and child. It is known as the ideal food
for babies, with important health benefits for
baby and for mother (Hale, 2007). Benefits
include both physical and psychological
aspects. Ku and Chow (2010) stated that
breastfeeding is considered as the best way
to give a nutrition to infant. According to
World Health Organization (2012), an annual
report by the UN Inter-agency Group for
Child Mortality Estimation shows that in
2011, around 6.9 million children died before
the age of 5 years compared to around 12
million in 1990.
Several years ago, UNICEF (United
International Regulation of Children
Foundation) identified seven easy, practical,
and effective steps towards saving the
millions of lives of these children. Exclusive
breastfeeding results in a delay in return
to fertility and helps space the mother's
pregnancies. Furthermore, breastfeeding may
lower the risk of cancers of the ovary and
breast of the women (Breastfeeding Trends
and Updated National Health Objectives
for Exclusive Breastfeeding United States,
2007). As a result, WHO was launched a
Baby Friendly Hospital Initiative (BFHI) in
Ankara, Turkey in June 1991 with a view
to fully support and promote breastfeeding.
Then every year a date - 1st to 7th of August
is declared as “Breast Feeding Week”.
Exclusive breastfeeding for the first six
months of life and continued breastfeeding
with complementary foods for the first two
years and beyond is recommended (Kramer
& Kakuma, 2012; Ku & Chow, 2010). The
American Academy of Pediatrics (2012)
also has made similar recommendations for
exclusive breastfeeding above. According
to the most recent statistics released by the
Centers for Disease Control and Prevention
(CDC) in 2008, 74% of U.S. women initiated
breastfeeding, 43% breastfed for six months,
and 21% breastfed for one year. African
American women with 61% initiating
breastfeeding, 29% breastfeeding for six
months, and only 13% breastfeeding for
one year showed the greatest improvements
of any population group in these statistics
180
but still fell far short of other groups (CDC,
2008). A study in Argentina revealed that
at four months post-delivery the exclusive
breastfeeding rate was 56% and at six months
it was only 19% (Cernadas, Noceda, Barrera,
Martinez, & Garsd, 2003). While in Georgia,
Russia, the exclusive breastfeeding rate at
four months was 18% (UNICEF, 2006). In
a study of feeding practices in 105 counties
of rural China, 98.22% of the 20.914 babies
in the study were breastfed. While in the
urban areas the percentage of exclusive
breastfeeding was 52% in the first four
months after birth and 24.35% in the rural
areas (Wang, Wang, & Kang, 2005).
The situation among Hong Kong Chinese
is not optimistic. Surveys conducted by
the Hongkong government revealed that
breastfeeding is very common, with 70%
of the new mothers practicing breastfeeding
in 2006. However, it was only 13% who
practicing exclusive breastfeeding at four
to six months after delivery (Ku & Chow,
2010). Another Asian country, Singapore,
also shared a similar trend. The National
Breastfeeding Survey 2001 in Singapore
demonstrated an encouraging breastfeeding
initiation rate of 94.5%, but only 21.1% of
mothers continued to breastfeed after six
months, with fewer than 5% breastfeeding
exclusively (Foo, Quek, Ng, Lim, &
Deurenberg-Yap, 2005). In Taiwan, between
the 1960s and 1980s, the prevalence of
breastfeeding had shown a significant decline
(Chen & Chi, 2000). Chien, Chu, Tai, and Lin
(2005) reported that in 2003 in Taiwan the
prevalence of exclusive breastfeeding was
17.9% during hospitalization, 22.3% at one
month, and 16.7% at 3 months. These low
rates of exclusive breastfeeding has been a
public health challenge in Taiwan.
The decreasing rates of exclusive
breastfeeding in the first six months also
happen in Indonesia. It fell from 40% in 2002
to 32% in 2007 (UNICEF, 2012). Recently
research in 2010 undertaken by ministry of
women and child protection has shown that
mothers who had provided their breast milk
to their babies exclusively for six months was
only 14%. The average baby in Indonesia
only received exclusive breastfeeding for
less than two months. The results issued by
Volume 2 Nomor 3 Desember 2014
Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
Indonesia demographic and health survey
(IDHS) in the period 1997-2003 is quite
alarming. Infants who breastfed exclusively
were very low. About 86% of babies get food
such as milk formula, solid food, or a mixture
of milk and milk formula. Furthermore,
Director of Public Health Nutrition at the
Department of Health (MOH) Ina Hernia
explained that the low breastfeeding rates
would be bad for the health of affected
infants. She referred to research in Ghana,
which showed that if the baby is breastfed on
the first day of birth, 16% of newborn deaths
could be prevented. ''In addition baby's life
expectancy will increase to 22% if the infant
is breastfed at one hour of birth,'' Ina said on
the sidelines of world breastfeeding week
campaign in Jakarta (Ministry of women and
child protection, 2010). Another researcher
also found nationwide data in Indonesia has
shown a low rate of infant who experience
early initiation of breastfeeding. It’s only
39% of them who breastfed within one hour
after birth and 32% are exclusively breastfed
for less than six months.
The low rates of breastfeeding practices
are influenced by many factors. Privacy and
emotional aspect can be that factors. Leff,
Gagne, and Jefferis (1994) described about
the bonding aspect in breastfeeding. He stated
that breastfeeding is a unique intimacy which
requires togetherness between mother and
baby to meet their physical and emotional
needs (Leff, Gagne, & Jefferis, 1994). He
added that an imbalance in the system
which was not corrected was associated with
unsuccessful breastfeeding (Leff, Gagne,
& Jefferis, 1994). Therefore, the maternal
perception of breastfeeding success seems
to be a dynamic concept and changing needs
must be recognized, balanced and satisfied
(Leff, Gagne, & Jefferis, 1994). New mothers
may find it is hard to learn breastfeed on the
busy postpartum unit, when she did not get
any privacy.
The decision to initiate and continue
breastfeeding is influenced by many aspects.
It is supported by the evidence showing
that religion, maternal education, mother’s
comfort in breastfeeding, social class, and
father’s occupation are related to the decision
to initiate and continue the breastfeeding
Volume 2 Nomor 3 Desember 2014
(Venancio & Monteiro, 2006; Kelly & Watt,
2005; Duong, Lee, & Binns 2005). Other
aspects, such as the desires or attitudes of
mothers regarding
Breastfeeding, mother-infant bonding, family
support, mode of delivery and a history of
smoking, are important in the initiation and
sustaining breastfeeding (Beck & Watson,
2008; Chandrashekhar, et al.,2007; SCOTT,
BINNS, & Aroni, 1997).
According to Beck and Watson (2008),
another aspect which has an important part
too in supporting women’s breastfeeding is
family. Similarly, Ingram and Johnson (2004)
showed how family played an important role
in supporting the mothers to successfully
initiate and maintain breastfeeding. Graffy
and Taylor (2005) has stated that it was not
only health workers who responsible for
mother’s breastfeeding practices, but families
and friends also play their part. A study of
the perceptions of Swedish women about
support from partners and grandmothers
highlighted how the woman's social network,
including grandmothers played an important
part in determining a woman's ability to
cope with breastfeeding (Reid, Schmied,
& Beale, 2010). Furthermore, members of
Swedish women’s social support networks
also determine the infant feeding decision.
The baby’s father is more likely the most
influential, followed by the woman’s mother,
family, and friends (Humphreys, Thompson,
& Miner, 1998).
There is a different understanding about
supportive. William (2005) cited in Reid,
et al. (2010) stated that new mothers and
grandmothers have different understandings
about what is supportive. Meyerink and
Marquis (2002) cited in Reid, et al. (2010)
identified that influence of the grandmother is
more felt by low income women. It also stated
that women themselves report emotional
support for breastfeeding is crucial. This
demonstrates the need to understand the
grandmother's role in providing support
for new mothers to achieving a positive
breastfeeding experience.
South Asian mothers were more likely
than white mothers to have received their
advice about pregnancy and baby feeding
from other family members. Mothers in all
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Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
ethnic minority groups received most advice
about baby feeding from their own mother
or mother-in-law (Thomas & Avery 1997).
Previously we have shown that if a mother
feels that she is encouraged and supported to
continue breastfeeding by all family members
and health professionals she is much more
likely to be breastfeeding her baby at six
weeks (Ingram, Johnson, & Greenwood,
2002).
Since the lack of family member support
of breastfeeding could be contributing to
women choosing to breastfeed their children
not exclusively, it is conceivable to evaluate
the available evidence about the effectiveness,
benefits and possible disadvantages for the use
of family member support for breastfeeding
and identify if there are gaps in mainstream
practice.
Furthermore it is timely and worthwhile to
produce a systematic appraisal of qualitative
studies to identify gaps and summarize the
existing literature exploring women’s and
family member views, on breastfeeding
and how family member support the
women breastfeed their babies exclusively.
Understanding factors that influence women’s
decision about the breastfeeding whether
exclusive or not may also inform strategies to
address misconceptions about breastfeeding.
Systematic reviews summarize critically
appraised research evidence related to a
specific question. Such reviews employ and
document comprehensive search strategies
and rigorous, transparent appraisal methods.
Bias is minimized when applying standardized
methods to the review process were done by
a group of experts, rather than individuals
(Dearholt & Dang, 2012). It involves the
application of strategies which limit bias in
the assembly, critical appraisal, and synthesis
of all relevant studies on a specific topic
(Chalmers, Hedges, and Cooper, 2002 cited
in Wholey et al, 2011). The word bias has
several meanings. Identifying and depending
only on reports which suit the reviewer’s
ideological or theoretical preference is an
obvious source of bias (Wholey et al, 2011).
Systematic reviews are scientific research,
and also the application of common sense.
They identify studies which relevant to a
particular question, then appraise and assess
182
the eligibility of these studies, and finally they
summarize them using statistical techniques
to combine their results. Without systematic
reviews, we are faced with an ever increasing
number of individual studies (Webb & Roe,
2008).
Metaanalysis or metasynthesis often use in
systematic reviews to summarize the results
of independent studies. When systematic
reviews summarize the results of independent
quantitative studies, they are referred to as a
metaanalysis. Metaanalysis provides a more
precise estimate of the effects of health
care interventions than those derived from
individual studies included in the review
(Higgins and Green, 2011 cited in Dearholt
& Dang, 2012). Through the use of statistical
methods, metaanalysis aids in understanding
the consistency of evidence across studies.
When a systematic review summarizes the
results of independent qualitative studies,
they are referred to as a metasynthesis. In a
systematic review with a metasynthesis, an
attempt is made to combine results from a
number of qualitative studies to arrive at a
deeper understanding of the phenomenon
under review. Metasynthesis produces a
broader interpretation than can be gained
from a single qualitative study (Dearholt &
Dang, 2012). Systematic reviews are needed
both to place the research in context and also
to ensure that new research is designed and
implemented in the most appropriate way
(Webb & Roe, 2008)
Research Aim and Question
Based on the data shown above, the objective
and aims of the appraisal are to collate
qualitative evidence concerning factors
which promote or inhibit the update and
maintenance of breastfeeding practices.
The specific objective include: to explore
published evidence of women’s views
on exclusive breastfeeding in developing
countries and to explore published evidence
concerning the interaction between women
and family members regarding supporting
exclusive breastfeeding in developing
countries.
There are the specific questions include:
what specific factors might influence
women’s views on exclusive breastfeeding,
what generalizations can be made about the
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Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
Table 1 Selection of Studies: Inclusion and Exclusion Criteria
Inclusion Criteria
Qualitative studies of experience (including but not
limited to design such as surveys, interview studies,
focus group studies, ethnography, phenomenology,
grounded theory, and narrative text.
English language papers
Primary research papers
Availability of full text articles
Papers published between the years 1990 and the
present
women’s view on exclusive breastfeeding,
what generalizations can be made about
a family member’s view on exclusive
breastfeeding, what generalizations can be
made about how family members influence
women’s view on exclusive breastfeeding,
and what generalizations can be made about
how family members provide support for
exclusive breastfeeding practices.
Method
An extensive of the literature between 1990
and present using all identified keywords
and index terms used by respective databases
was undertaken. This is because the literature
before 1990 considered to be too old to be
Table 2 The Included Studies and Their Labels
Study Title
Engaging and supporting fathers to promote breastfeeding: a
new role for Health Visitors?
Exploring women’s views of breastfeeding:
A focus group study within an area with high levels of
socioeconomic deprivation
Grandmother Breastfeeding Support:
What Do Mothers Need and Want?
‘I only give advice if I am asked’: Examining the
Grandmother’s potential to influence infant feeding
Decisions and parenting practices of new mothers
Practices and beliefs about exclusive breastfeeding by
women living in Commune 5 in Cali, Colombia
Psychosocial factors underlying the mother’s decision to
continue exclusive breastfeeding for 6 months: an elicitation
study
Volume 2 Nomor 3 Desember 2014
Exclusion Criteria
Experimental research including randomized
controlled trial (RCTs) and control trial
Non – English language papers
Review of primary research papers,
Abstract only
Papers published before the years 1990
taken, so therefor it could be bias for the
result. The following literature databases
were searched using these key words, such
as: breastfeeding, exclusive breastfeeding,
infant breastfeeding, factors influencing
exclusive breastfeeding, family role,
family support, social support, benefit of
breastfeeding, experience and expectation
of breastfeeding. Database searched were:
medical literature analysis and retrieval
system online (MEDLINE, 1971–2011),
cumulative index to nursing and allied health
literature (CINAHL, 1965 – 2012), BioMed
central (1974–2010), Wiley (1987–2011), and
ecerpta medical database (EMBASE, 1981-
2010). Publications were limited to English
language only. Search were performed of the
references of the key papers included in the
Authors Label As
Sherif & Hall (2010) S1
McFadden & Toole (2006) S2
Grassley (2010) S3
Reid, Schmied, & Beale, 2010 S4
Hernández, L., & Vásquez, M. L. S5
(2010)
Bai, Middlestadt, Joanne Peng, and S6
Fly (2009)
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Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
review.
The etymology of the word evidence is
rooted in the concept of experience, relating to
what is real and clear (Upshur, 2001). Various
definitions of evidence-based practice (EBP)
have emerged in the literature. It has been
defined as the conscientious, explicit, and
judicious use of the current best evidence in
making decisions about the care of individual
patients (Sackett, Rosenberg, Gray, Hayes,
& Richardson, 1996). Then, Burns & Grove
(2006) stated that EBP is the conscientious
integration of best research evidence with
clinical expertise and patient values and needs
in the delivery of quality, cost effective health
care. Best research evidence is produced by
the conduct and synthesis of numerous, high
quality studies in a specific health area (Burns
& Grove, 2006).
The evidence based practice movement
defines a hierarchy of research methods
suitable for addressing the clinical question.
At the top of the hierarchy is quantitative
randomized controlled trial (RCT) known as
the gold standard. Large scale quantitative
studies especially RCTs have become the
accepted paradigm for the construction of
medical knowledge.
As the breastfeeding experience of a
woman is too complex and multifaceted to
be appropriately considered within trails
alone, this appraisal includes qualitative
studies of experience (including but not
limited to design such as surveys, interview
studies, focus group studies, phenomenology,
and narrative text) on women’s and family
member’s view on exclusive breastfeeding.
Evidence from the qualitative studies which
collected and reported using randomized
trials would be difficult to retrieve. The
component of the review will consider
studies that include the following outcomes,
such as factors influence women’s view on
exclusive breastfeeding, women’s view on
exclusive breastfeeding, family member’s
view on exclusive breastfeeding, and family
member’s support on women on exclusive
breastfeeding practices.
The searching of related literature was
conducted using Boolean search terms
included ‘and’ which retrieves only article
with both words (example exclusive
184
breastfeeding and family support), and ‘or’
which would located all articles with either
words. Author searching was conducted
by searching each database for the name of
authors of relevant reports to ascertain if they
published other or similar work on the topics
of interest. Publications were limited to the
English language only. The following search
terms were used in all databases as listed in
the identifiers below. The identifiers were
combined with the phenomenon and design
with ‘and’.
It is important to set out the inclusion
criteria in the protocol, to ensure that the
boundaries of the review question are
clearly defined (CRD, 2009). The inclusion
and exclusion criteria determine the focus,
nature, and limits of the review. In order how
were the studies selected, a strict inclusion
and exclusion criteria checklist (Table 1) was
used. Studies were eligible for inclusion if
they met the following criteria to determine
whether each paper was suitable for further
quality checking.
Result
The search yielded 341 citations. Of these
324 were ineligible after review of the title
and abstract. Papers excluded were those that
had a quantitative assessment only (n=186),
did not include women or family’s view on
exclusive breastfeeding (n= 48), non-primary
research (n=36), duplicate articles (n=21),
and intervention studies (n=26). The eleven
full text papers that were excluded were
either because the focus was on qualitative
assessment (n=8) and non-primary research
(n=3).
The studies used focused group and indepth
semi structure interview from 105 mothers,
eight fathers, and 11 grandmothers who
gave their views, preference experience, and
expectations on exclusive breastfeeding. The
studies were carried out in Columbia (n=15),
North-east of England (n=35), Brighton and
Hove – UK (n=8), North America (n=30),
Indiana – USA (n=25), and New South Wales
– Australia (n=11). Four studies had women
as their study participant (S1, S2, S4, S5)
while fathers were participants for one study
Volume 2 Nomor 3 Desember 2014
Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
(S3) and grandmothers were participant for
another one study (S6).
Various data collection method were used
with one study using more than one method,
which included in-depth interview (S1 & S3),
semi-structure face to face interview (S6),
focus group (S2, S4, S6), and open-ended
questionnaire (S5). All six studies specified
the sample size and characteristic of the
participants (S1,S2,S3,S4,S5,S6).
Discussion
The first theme of result studies is about
positive or negative view on breastfeeding.
A central theme that links other themes and
sub-themes are positive and negative view
on exclusive breastfeeding. Most mothers
were viewed breastfeeding as an important
thing to do. It has a lot of benefit both for
infant and the mother itself (S1, S2, S5). Two
studies found that infant who had breastfed
will be healthier and smarter in the future
(S1 & S2). Then one study mentioned that
one of the advantages of breastfeeding is
helping mother to have bonded with the baby
(S5). For emotional aspect, one study stated
that women place a very high value on the
emotional and health benefits of continued
exclusive breastfeeding for six months (S5).
In contrast, there are also some view about
a disagreement of exclusive breastfeeding
by the mothers. One study found that some
mothers were not preferred breastfeed the
baby if it makes the baby feel not comfort as
manifested by continues weeping (S1). Again
this study found that some mothers felt breast
milk was not enough for the baby which can
make baby remaining hungry. It induced
them to start the child with a complementary
diet prior to six months of age. Then another
study found that bottle feeding was perceived
to be easier, incurring fewer problems and
resulting in infants that were more settled,
chubbier and needing less frequent feeds (S2).
About reason why some mothers did not offer
exclusive breastfeeding, one study found that
the reason is remembering the process as
something painful and difficult (S1). They
assured that the most painful moment was
breastfeeding the baby and not childbirth.
Volume 2 Nomor 3 Desember 2014
Many of the women appeared tentative in
their decision to breastfeed because they
anticipated problems and lacked confidence
in their ability (S2). Then in this study also
found the impact of breastfeeding on lifestyle
was significant for some mothers. Examples
included the lack of freedom to travel,
socialize and continue education and work.
These issues were particularly significant
for the adolescent women and were quoted
as a reason for choosing bottlefeeding.
Then about factors which underpin mothers
breastfeed their child, one study found that
women who chose breastfeeding having been
breastfed themselves, or had sibling who had
been breastfed (S2).
Mother’s view on exclusive breastfeeding
is an important part in an attempt to
promote breastfeeding desire. Even though
their view is influenced by her family and
surroundings, but finally the decision is on
her. A researcher found that the single most
influential motivator for breastfeeding is the
mothers desire her selves (Burns & Grove,
2009). Then these views also influenced by
the mother’s experience of breastfeeding.
This concurs with the finding of some
researcher who found women who have
the experience of breastfeeding, especially
within the family, are more likely to choose
to breastfeed their child (Hoddinott & Pill
1999). The view on this breastfeeding also
involving how the mothers see the role of her
family and surroundings in supporting them
breastfeed the babies exclusively. Schmied,
Beake, Sheehan, McCourt, & Dykes (2011)
stated that women who breastfeed their
babies mentioned an advantage of peer
supporters was that they could spend enough
time with the woman to make a difference,
to provide feedback and tips or information
that was centered on the personal needs of
the mother and baby. Meanwhile, Burns and
Grove (2009) also found that the majority
of women who breastfeed their babies
identified breastfeeding as a natural and this
is important for making bonded attachment
between mother and baby.
The view on breastfeeding in this systematic
appraisal also involves the family member’s
view. Family member of the mother of this
systematic appraisal mostly are grandmother
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Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
and the spouse of the mother. There are
varying views on exclusive breastfeeding.
In one study found that breastfeeding
considered as the best nutrition for the baby.
It stated that breastfeeding is natural, free,
and normal (S3). In other side, mostly the
family member (spouse) on the study were
unable to articulate clearly the benefits of
breastfeeding and its nonequivalence with
formula. They mentioned that any literature
about breastfeeding are needed, because it
was meant for them to understand clearly
what is exclusive breastfeeding and what is
the role of the spouse to facilitate the mother
breastfeed the baby exclusively (S3). In three
studies found that exclusive breastfeeding
considered as an important thing which
is involving the mother’s family and
surroundings to encourage and motivate her
breastfed the baby exclusively (S2, S3, S6).
This concurs with the finding of the authors
who found that the attitude of partner, mother,
and peer groups are the factors that influence
the initiation of breastfeeding (Protheroe et al,
2003). It also concurs with another researcher
who found that in Bristol, grandmothers have
a key role to support and influence mothers to
breastfeed (Ingram, et al., 2003).
Conversely, one study stated something
contrast with studies found above. It found
that grandmothers view breastfeeding as an
obstacle to mothers getting enough rest. It
mentioned that breastfeed the baby especially
at midnight will interfere with mother’s
bedtime. One mother described how she felt
pressured to give formula to her infant as
the solution to getting more sleep. She felt
pressured because the grandmother forced
her to prefer giving formula milk rather than
breastfeeding (S4). Then it also found that
mothers want the grandmothers to confront
myths about breastfeeding. The influence
of grandmother as a family of the mother is
strong. One study which has concurred with
this found that family and friends were cited
most frequently as being influential in the
women’s decision of infant feeding method
(S1). This is also concur with another study
which found grandmothers are an important
part of the support network for new mothers
and can potentially be an influencing factor
in terms of their breastfeeding and parenting
186
decisions (S6). So it can be seen how strong
the influence of the grandmother of the
mother. Sometimes it will be not good for
the mother, because the grandmother’s era is
not always the same with the mother’s era.
This is in accordance with the finding of one
study which is found that grandmothers bring
their own infant feeding practices and beliefs
to their support of new mothers (S4). This is
concurring with another study which is found
if they use the power they have from the other
levels of interaction they may not be able to
preserve a good relationship with the new
mother (S6). Nevertheless, the grandmothers
still have a good view about breastfeeding.
One study found that grandmothers valued
breastfeeding when they offer a loving
encouragement (S4).
Associated with stopping breastfeeding,
one study discussed about the reason of
this (S2). It found that based on mother’s
spouse’s opinion, stopping breastfeeding
may stem from feelings of frustration and
guilt, and also efficacy on behalf of the father
about ‘not being able to help’. Therefore by
changing to formula can sometimes be seen
as an easier option. They thought it would
reduce the guilt feeling (S2).
It is reasonable to assume that mother
viewed the exclusive breastfeeding as an
important part of many things. For emotional
aspect, it can create bonding-attachment
between mother and baby. This concurs with
finding of the researcher who found that
mother-child relationship as an integrated
whole. Breastfeeding is seen as an important
emotional bond between mother and child
to be encouraged and supported as much as
possible (Zwedberg & Naeslund, 2011). It
showed how the mothers would feel so close
to the babies when breastfeed them. Bonding
attachment is something which is very
important for a mother and child relationship.
This can foster feelings of affection between
them which will lead to the formation of
harmonious relationship within the family.
Furthermore, this can be seen breastfeeding
is based on collaboration between mother
and child. Then another reason why mother
view exclusive breastfeeding as an important
thing is the understanding of the mother
about benefits of breastfeeding. This agrees
Volume 2 Nomor 3 Desember 2014
Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
with the finding of the researcher who stated
that women acknowledge the benefits of
breastfeeding for the baby including the
nutritional or nourishing aspects and the
provision of the immunity (Burns & Grove,
2009).
Mother’s view on exclusive breastfeeding
has some implication for certain things.
For nursing practice, it will stimulate the
community nurse or midwives to modify
strategies to facilitate mother breastfeed the
baby exclusively. The varying view of the
mother would make nurses and midwives
think about the best way to encourage the
mothers to breastfeed the baby exclusively.
This is a responsibility of the nurse and
midwives as a health care provider to facilitate
the process. As WHO recommendation which
stated that breastfeeding should be done for 6
months exclusively, the nurses and midwives
will find the best way to make it happen.
The second theme of this study is
family’s influence and support on exclusive
breastfeeding practices. Family member is
an important part of continued breastfeeding
until six months. One study found that
exclusive breastfeeding greatly depends on
the relationship between mother and her
family and surroundings. The mothers stated
that family role is very important to support
them offer exclusive breastfeeding (S1).
Then another study found that friends and
family members were frequently mentioned
as salient social referents. Then spouse
and friends have been the most frequently
mentioned approving referents (S5).
Regarding support on exclusive
breastfeeding, two studies found that the
family of mothers is very interested in proving
support in breastfeeding. They really want to
be involved more broadly (S3 & S6). One
study which is using father (mother’s spouse)
as the participant found that the fathers are
really interested and want to be involved more
broadly in preparation for, and supporting of
exclusive breastfeeding (S3). Another study
which is using grandmothers as the participant
found that the grandmothers are very positive
in providing support and they really want to
be available to help (S6). They felt they had
to help with breastfeeding directly because
Volume 2 Nomor 3 Desember 2014
the mothers did not get the help they needed
from midwives and other health professionals.
Grandmothers may position themselves as
being accessible for advice and support they
did not want to be too intrusive (S6). Then in
another study, Grandmothers communicated
that they valued breastfeeding when they
offered loving encouragement (S4). Those
studies showed how much support given
by the family of the mother to encourage
mothers breastfeed their baby exclusively.
This concurs with the previous study which
is found grandmothers have a key role
in supporting and influencing mother to
breastfeed (S2). In one study, it is shown how
the serious father (mother’s spouse) to provide
support for breastfeeding for the mothers. It
found that in term of antenatal provision, they
had attended the antenatal classes (S3). Then
still in this study, it found if the fathers were
not able to attend the class, this is caused
by conflict with works. Most of them then
mentioned the session of antenatal classes for
working fathers should be accessible (S3).
Meanwhile, although the fathers supported
their partners’ decision to breastfeed, they
also felt that using formula could allow them
to be more involved in feeding, assist them to
bond, help the baby sleep through the night,
and help to monitor how much the baby was
taking (S3). It described how big the desire
of the father to be involved in breastfeeding.
Therefore they thought by using formula
milk, the involvement of them will be seen.
They can give the formula directly to the baby
by their own hand. Then in another study, it
also described about a little disagreement
of breastfeeding as mentioned. It found that
grandmother sometimes were disagreeing
with breastfeeding method when the mother
would like to feed the baby. It mentioned
that the mother would be better if she use
formula milk rather than breastfeeding as this
breastfeeding could make the mother woke up
in the night and make her tired because of less
sleep (S4). It showed how the grandmothers
felt so worried about the condition of the
mother when feeding the baby.
It is reasonable to assume that if the family
give a strong support, the mother are more
likely to successfully initiate and maintain
breastfeeding (Ingram & Johnson, 2004).
187
Iqbal Pramukti: A Metasynthesize of Mother and Family’s View on Exclusive Breastfeeding
The mother will feel more confidence if they
are supported by the family. This can be seen
that mother’s behavior often influenced by
family, especially adolescent mothers who
had less experience on breastfeed a baby.
It has some positive impact which is finally
contributed to exclusive breastfeeding
practices. A recent research found that mother
who got a support from her spouse would
have a partner to share about a decision of
infant feeding (Burns et al, 2009a). Then
the researcher also found that having a
mother who breastfed and was supportive
also facilitated sustainable breastfeeding for
women in initiating exclusive breastfeeding
for 6 months as recommended by World
Health Organization.
The implication of the family involvement
in supporting mothers to breastfeed for
nursing practice is the more needs of mother
and family to be facilitated in harmonizing the
relationship within them. They need nurses
to give them support and encouragement,
especially about transferring knowledge and
feeling about the importance of breastfeeding.
Conclusion
It is reasonable to assume that if the family
give a strong support, the mother are more
likely to successfully initiate and maintain
breastfeeding. The mother will feel more
confidence if they are supported by the
family. This can be seen that mother’s
behavior often influenced by family,
especially adolescent mothers who had less
experience on breastfeed a baby.It has some
positive impact which is finally contributed
to exclusive breastfeeding practices. A recent
research found that mother who got a support
from her spouse would have a partner to
share about a decision of infant feeding.
Then the researcher also found that having
a mother who breastfed and was supportive
also facilitated sustainable breastfeeding for
women in initiating exclusive breastfeeding
for six months as recommended by World
Health Organization.
The implication of the family involvement
in supporting mothers to breastfeed for
nursing practice is the more needs of mother
and family to be facilitated in harmonizing the
188
relationship within them. They need nurses
to give them support and encouragement,
especially about transferring knowledge and
feeling about the importance of breastfeeding.
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